P2597 Hwy 601SDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit .Number
Name ifi r ;; Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES ❑ NO ❑
Type Water Supply
"This permit Void if sewage system described below is not installed within 36 months from date of,issue.
I
j
,r • ••. Apr
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Improvements permit by -'
`Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
� �
Certificate of Completion - ` l `~ �� Date.. "'�
'The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
.»
DATE
LOCATION
FINDINGS:
LOT DIAGRM-1
2.
3.
4.
S.
6.
DAVIE COUNTY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
HOLE NO.
l
By:
C��
e�i,r,14Y
DAVIE COMITY HEALTH DEPARTME14T
ENVIRONMENTAL HEALTH SECTION
P. O. BOX 57 V
MOCKSVILLE, N.C. 27028-
(704)
7028(704) 634-5985
Statement for Se tic Tank rovements Permits and/or S e val ati9ns
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NAME ( / DATE /
ADDRESS f f �/ PERPiIT I4O. !�
EXPLANATION OF CHARGE44f�;;ZWI
/ � ''�� ✓J3vZr
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AMOUNT DUE i . �� SAtJITARIAN
PLEASE REMIT THE ABOVE A11OUNT ON RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Improvements Permit(s) can not be issued until payment is received.